Politics of Public Policy Implementation: Case of Ghana National Health Insurance Scheme
It involves a general political and technical process of enforcing government intentions, decisions, and programs to address societal pressing demands or needs.
- Public policy
It is a general course of action or inaction followed by a government or its agents in dealing with a problem or matter of concern. Such course of action or inaction is targeted at peculiar outcomes.
It involves the use of state authority and [discretion] to determine how policies, decisions and resources target particular groups or sectors (perhaps and not others) in a political system at any given time. Many forces and considerations do shape how policies get designed, including the pattern and manner of implementation. Politics determines the questions of society entailing who gets what, how and when [and perhaps who pays] (Lasswell 1936)
Why do most policies attempted at addressing socioeconomic woes in developing countries fail? Are there missing links or gaps in the policy process? These questions have occupied center stage in the continuing debate over the capability of developing countries to deal with the myriad of socioeconomic challenges confronting them. One school of thought points to the inability of the state to design context-relevant policies and programs to deal with context-specific problems (see Massey 2009 on mimetic isomorphism and coercive isomorphism which suggest directly transferring policies from one context to the other). Many other analysts argue that there are several well-designed and well-intended policies, but the missing link is rather [enforcement laxities] the knack and will of the state and its institutions to effectively implement these policies (Brinkerhoff 2000).
Although stages in the policy process are closely interwoven, the implementation stage is of critical importance to the success of governments in the quest to addressing socioeconomic challenges. This point is forcefully brought home by Sapru (2004) who contends that “however good the political system, however noble the goals, however sound the organizational structure, no policies can succeed if the implementation does not bear relationship to the intentions of the policy adopters…studies show that the implementation stage is the most important and yet the most neglected” (Sapru 2004: 149). The conclusions of several studies and discussions have been that the policies exist; rather what is left is effective implementation (Carbone 2011; Tetteh 2012).
Besides the acknowledgment that the implementation process is administrative or technical in nature, it is also largely political and involves governance decisions, appointments, coalitions, and networks in dealing with complex and ill-defined societal problems, especially in the post-NPM era of network governance (see Salamon 2002). This makes it imperative for scholars to reflect on how the practical and political complexities of policy implementation can offset the potential net gains, so that societies are not drawn into a cycle of merely replacing failed policies with newer and perceived better ones. How does politics influence public policy implementation? The circumstances surrounding Ghana’s National Health Insurance Scheme provide prima facie case of how politics could affect a policy process; however, the literature has left this phenomenon [politics conundrum] largely under discussed. The main object of this study is to examine the political milieu of the NHIS policy cycle with special focus on the implementation phase. This paper makes a modest contribution to the literature on political context of social interventions in African countries by adequately discussing five political elements which shrouds Ghana’s NHIS that have hindered the effective implementation: The political haste in passage of the bill into law; technical and political imperatives [technical alienation?]; power play among actors and institutions; appearance of partisanship in strategic appointments and ‘street-level’ politicking.
Politics and Implementation
Over the years, there has been the realization that implementation is not merely a technical exercise but also an inherently political activity. Thus, implementation of policies involves far more than a mechanical translation of goals into routine procedures. Ripley and Franklin (1986) argue that the perceptions held by individuals involved in implementation of programs and policies about what is at stake in the decisions that must be made have an important impact on the nature of politics surrounding implementation. In other words, the nature or type of policy determines the politics around it. Grindle (1980) also contends that implementation involves fundamental questions about conflict, decision-making, and who gets what in a society (see also Lasswell 1936). The author contends that implementation is frequently a highly political process and that the implementation stage is an arena where those with interest in a policy engage in negotiations over the goals of the policy as well as conflicts over the allocation of resources. Thus, there are numerous political clashes over the allocation of resources at the implementation stage. These clashes are also characterized by politics based on factions, patron-client ties, and other affective forms suited to individualized demand on the bureaucratic apparatus for the allocation of goods and services (Grindle 1980). It is this interaction that these scholars refer to as the politics of implementation, thereby underscoring the existence of a politics-implementation nexus.
In the contemporary literature on policy implementation, particularly, on developing countries, the crucial role of politics in implementation is captured by the concept of political settlement (see, e.g., Khan 2011). The term “political settlement” is used to describe the informal power arrangements between and among key actors, interests, and institutions in a country or a “social order” within the system. The concept captures the complexities that come about as political, and sometimes bureaucratic actors use their influence to shape and control formal governance structures and policies to advance their own interests. In most cases, it is this coalition of powerful elite factions making up the key actors in a political settlement that determines the nature, form, and direction of public policies and not how well thought through the policies are or how well resourced the implementing institutions are (Khan 2011). Abdulai and Hulme (2015) reinforce the dominance of political settlement in developing countries when they argue that effective implementation of public policies is not necessarily the result of good formulation per se but the extent to which the power relationships surrounding those polices agree. From this perspective, policy implementation is seen as resulting from an intense process of inter-elite bargaining and can only be effectively implemented to the extent that those who have the “holding power” agree to the rules of the game (ibid). This view is quite instructive because it directs attention to the inherent structural influences that bear strongly on the implementation process. The essence of this perspective lies in the acknowledgment that even if all the other factors (resources, effective communication, and a well-resourced implementing agency) are met, it will take some consensus on the part of the power holders to guarantee effective implementation.
The study is positioned within content analysis of qualitative research approach. It is largely driven by secondary sources of data. The design is a content analysis of relevant policy documents including, inter alia, NHIA Act 650 of 2003, political party manifestoes [1996 and 2000 manifestoes of NDC and NPP prior to 2000 elections that influenced the birth of NHIS in 2003], and other written reports. The data is sourced from government agencies and their websites, conference and lecture proceedings, newspaper publications, and journal articles.
Political Context of the Policy: The Haste and Laxities in the NHIS Bill/Law
Discussions of the possibility of a universal health policy in Ghana had always been in the background in the 1990s, though it became a key electoral issue in the heat to the 2000 general elections (Ayee 2001). For the New Patriotic Party (NPP), even while in opposition, the party had condemned the then existing “cash-and-carry” system as “notoriously callous and inhuman” and promised to replace it with a more equitable system of health insurance. The NPP’s election platform made it plain that the party would “abolish the iniquitous cash-and-carry system,” so that “nobody in Ghana will be denied medical attention because of his or her inability to pay and that payment of fees, if any, will be discussed when the patient is out of danger” (NPP Manifesto 1996: 36–37). Hence, for Ayee (2001), the health reform introduced by the NPP was the result of its long-standing effort to capitalize on the unpopularity of cash-and-carry.
A content analysis of the ruling party at the time, the National Democratic Congress (NDC) pre-2000 election manifesto, reveals their own political indifference, slowness, and inability to offer an immediate alternative to replace their unpopular cash-and-carry system. As indicated in their manifesto, they maintained that “feasibility studies on the proposed Health Insurance Scheme had been completed, the scheme will be tested on a pilot basis and if successful, it will be introduced on a national scale” (NDC 1996). Haunted by pressure from Ghanaians and their main political opponents, the NPP, they hurriedly broadcast an alternative strategy on the eve of the 2000 election; a proposal of a “mix of insurance schemes” which was meant to work side by side with a “reviewed” and “improved” cash-and-carry system rather than fully replacing it (NDC 2000).
It was within this politically charged context that the NHIS was implemented by the NPP in 2003, 3 years after winning power. Indeed for a country like Ghana – with a quarter to a third of its people living in poverty, a high number of informal workers, a prevalence of rural dwellers, and a relatively poor infrastructure – this represented a bold policy, as the new legislation marked the first attempt in the region to institute a nationwide insurance scheme with the ambitious goal of achieving universal coverage (Sulzbach et al. 2005). Consequently, most Ghanaians welcomed the NHIS, although many opposed the government’s funding plan and the haste with which the bill was being processed. Organized groups particularly the trade unions and international bodies like the IMF advised the government to tread with caution (Wahab 2008). Be that as it may, the government felt pressed to stick to its own election pledges and sped up plans for the reform. According to Carbone (2011), this was mainly because the new government was anxiously on the lookout for concrete policies that it could showcase in seeking a renewal of political mandate in the next election. The government rushed through the processes just to fulfil a campaign promise in time, and this led to the failure to establish a full-proof mechanism of funding the scheme. It also left gaps in enforcing its core legalities as well as adequate deliberations with stakeholders (Agyepong and Adjei 2008; Wahab 2008). Though the bill got passed into law in the end, the battle lines had clearly been drawn and entrenched positions taken. The unresolved tensions and dissatisfactions were only transferred to the implementation stage (Grindle 1980).
This haste and poorly “muddled through” means of funding as well as failure to address accountability loopholes in the bill is what has led to the persistent financial albatross and associated corruption hanging around the neck of the scheme. The scheme has been battling with increasing debt owed various service providers in the country. Even with a current value added tax (VAT) rate of 17.5%, a National Health Insurance Levy of 2.5% and the Social Security and National Insurance Trust (SSNIT) contributing up to 94% of its funding, urgent calls are still being made for additional sources of funding to avert collapse of the NHIS (NHIA 2015).
Technical and Political Imperatives: Complementarity or Competition?
Contemporary public administration thinkers make a case for complementarity between policy-making and implementation critiquing the classical Wilsonian dichotomy. According to Svara (2001: 179) “in contrast to the politics–administration dichotomy, the complementarity view supports broader policy-making responsibilities for public administrators, along with significant involvement of elected officials in policy implementation…. administrators complement elected officials in the policy-making process by helping them shape policy and by giving it specific content and meaning in the process of implementation….” Owing to the significance of technical and expert role of technocrats, as early as 1966, Omanboe called for some restraint with political decisions after noting how all important projects at the time had to be initiated by politicians who committed their countries and people to certain courses of action before technocrats are consulted (Omanboe 1966). This raises a bigger question of whether politicians engage technocrats in a genuine and deliberative manner over policy content and processes or merely consult them as a mere formality?
In the case of Ghana’s NHIS, serious tensions characterized the implementation of the policy. The politicians after taking the decisions mainly based on political calculus also got involved in “bulldozing them through” in ways and manner that were sometimes incongruent with the technical plans of health planners and managers. Agyepong and Adjei (2008) point to the level of these tensions by noting that “as the work of the committee set up to design the health financing reform appeared to slow down because of technical concerns and recommending building on existing local mutual health organisations and continuing the piloting, its composition was changed to better reflect the political priorities and the haste of the executive.” Thus, no time could be wasted on technical details; new political nominees came to dominate the drafting process in the committee, whereas the traditionally strong role played by the technocrats of the Ministry of Health – some of whom were proving too cautious, or even sceptical, about the reform – was downsized (Atim et al. 2001). For instance, technical committees appeared to be rubber stamps in the process, “the trusted political associates remained so powerful in the decision-making process that sometimes technical working groups noted decisions on the issues they had been charged to work on had, in effect, already been taken” (Agyepong and Adjei 2008: 156). In his policy alienation framework, Tummers (2012) defines policy alienation as a form of strategic powerlessness conceptualized to involve a “form of powerlessness that occurs, for example, when a new policy is drafted without the help of professionals, for example, by failing to consult professional associations or labor unions” (Tummers 2012: 518). The unresolved conflicts with the NHIS consequently led to low patronage, particularly from the sceptics who adopted a “wait and see” attitude thereby stalling the building of the pool needed for effective implementation of a social insurance scheme especially at the initial phase (see Atim et al. 2001; Grindle 1980).
The Politics of Strategic Appointments: A Political Calculus
Several studies on the nature and functions of public services in Africa and other developing nations have relied heavily on the use of the concept of neo-patrimonial state (Kelsall 2011). This refers to the state in which there is a weak sense of the public good or of public service, and where the resources of the state are at the disposal of the executive (president and his ministers) who use these to reward and to co-opt adherents in a patron-client continuum. Like other public agencies, the National Health Insurance Authority (NHIA) has also been at the mercy of politicians. Characteristic of all public institutions, the government of the day reserves the right and responsibility to make appointments to the authority, especially, to the top positions. The chief executive officer (CEO) who oversees the management of the authority is appointed by the government and appointment to this position is largely done from a purely political calculus and logic. The main consideration has been “who will best serve our interest as a party or individual.” Thus, appointment of the NHIS boss changes when there is a change in government, and the two parties that have been in power since the implementation of NHIS have brought on board their own CEOs. This is consistent with the practice in Ghana, where heads of public institutions are predictably asked to proceed on leave whenever there are political alternations. In 2009 [ruling NPP government lost power in a general election], for instance, the CEO, Ras Boateng, was summarily replaced by Sylvester Mensah (NHIA 2009), a vociferous member of the ruling NDC [new government]. More worrisome is when key actors and officers of the scheme are seen in the media engaged in active partisan politics which appears to make the scheme and its implementation more politically underpinned.
Street Level Politics and Appointments
More related to the above, it appears one has to be a member of a particular political party [ruling party] at any point in time to be able to get a job at the NHIS which is been used as a “job for the boys” of the government of the day. Grounds for such belief abound in the Ghanaian media which reports local party members hijacking NHIS offices at the district level. In August of 2010, for instance, myjoyonline.com reported of rampaging youth of the NDC [ruling party] in the Zabzugu constituency in the Northern Region forcibly taking over the offices of the NHIS in the area. The irate youth allegedly chased out the scheme manager on suspicion that he is loyal to the New Patriotic Party [opposition party] and was getting NPP people [perhaps appointing objectively instead of giving jobs to only the ruling NDC members] on board. While these struggles are only a tip of the iceberg, it points to the twists and turns in tinkering with policies usually for political survival and perpetuation of party interest. It is within this context that civil society organizations (CSOs), for example, the moderator of the Presbyterian Church of Ghana, called for a cessation of the politicization of the operations of the NHIS in order not to cause its collapse, reechoing the need for the government to employ technocrats and not just party faithfuls (Daily Graphic, Sep 10 2015). On a key question of what makes a policy successful, Mead provides a swift answer that “in the recipe for success, strong administration is probably the most crucial single ingredient” (Mead 1997:122).
Conclusions and Policy Suggestions
This paper has analyzed the politics of the policy process and how it culminates in the implementation phase using the case of the NHIS in Ghana. The study has demonstrated that the implementation process is not just a technical exercise but also an inherently political activity. The experience of the NHIS points out that the phases in the policy process are very much interlinked and closely interwoven; the elements that occur in a prior stage feed into or have ramifications on the subsequent stages. In other words, there is a subsequent forward loop and the better we carry out the earlier phases, the smoother the subsequent stages. On the other hand, a well-rushed through or poorly “muddled through” policy formulation will meet the very challenges that were glossed over along the way. A policy-maker who fails to prudently address significant concerns at the formulation phase lives to fight or meet the same concerns [perhaps exacerbated] at the implementation phase.
Policy elites should endeavor to enable stakeholder involvement and some form of consensus and commitment from bureaucrats or administrators right from the formulation phase. We posit that politics should be managed in such a way that it does not deactivate the technical competence of the implementation machinery. This is because “no matter how clear the policy message, no matter the level of capacity of a given state, and despite an appropriate formal organizational structure, skillful and committed program management seems important for implementation success” (Goggin et al. 1990: 130). Logically, it is quintessential to distinguish or perhaps, balance political party commitment with meritocracy to effectively execute public policies; and the lines should be drawn clearly.
There is the need therefore for wider participation in the formulation and implementation processes by the population or at least the target group. As has been seen in the NHIS case, more often than not the target group is usually left out at the policy formulation stage, and the views of the few groups who have the opportunity to voice out concerns are easily ignored. The resultant policy so designed, therefore, fails to be client-oriented and alienates the very people for which it is targeted. The much needed ownership of the policy becomes difficult leading to apathy and subsequent failure.
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